| NPI | 1205249083 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: KY 53891) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: VA 0101258652) |
| Enumeration Date | 2014-06-09 |
| Last Update Date | 2021-08-12 |